Inspection on 21/11/05 for Wendover Road (87)

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wendover Road (87) 27/08/08

Wendover Road (87) 28/08/07

Wendover Road (87) 10/07/06

Wendover Road (87) 19/04/05

Wendover Road (87) 24/01/05

Wendover Road (87) 06/08/04

Wendover Road (87) 11/02/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Wendover Road (87) Stoke Mandeville Aylesbury Bucks HP22 5TD Lead Inspector Mrs Maureen Richards Unannounced Inspection 21st November 2005 09.40 Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wendover Road (87) Address Stoke Mandeville Aylesbury Bucks HP22 5TD 01296 615403 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 87wendrd@nildram.co.uk Hightown Praetorian & Churches Housing Association Care Home 4 Category(ies) of Learning disability (4), Physical disability (1) registration, with number of places Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home may care for one service user with a Physical Disability. That this condition applies to one specific service user, and should the service user in question leave the home for whatever reason this condition will cease to apply. That no further users with a physical disability are admitted to the home unless the home applies for a further variation to their registration. Date of last inspection 19th April 2005 Brief Description of the Service: 87 Wendover Road cares for 4 female service users with a learning disability. The home is located in a residential area about one mile from the centre of Stoke Mandeville. The home is a bungalow situated in relatively secluded grounds, with a large rear garden. All of the bedrooms are single and there is a kitchen / diner and a separate sitting room. The home has its own transport and is accessible to local amenities. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It started at 09.40 am and finished at 17.40. The inspection focused on some of the key standards and included an introduction to the service users, discussions with the manager, examining records, viewing policies and procedures and a walk around the home. The progress made towards meeting requirements and recommendations issued as a result of the last inspection was also assessed. It was established that progress has been made in addressing some of the requirements from the last inspection and some requirements have not been complied with which has been repeated at this inspection. What the service does well: What has improved since the last inspection? What they could do better: Service user plans must be further developed with the plan of care kept updated and reviewed. Service user plans need to be reorganised and key information made more easily accessible. Risk assessments including moving and handling assessments must be kept updated, reviewed and reflect the level of risk. The missing person procedure must be updated. Service users healthcare needs must be monitored effectively and changes acted on. Staff must be trained and competent to carry out specific treatments for example massage. Guidelines should be developed on the arrangements for the management of service users laundry. Staff files must be updated to include the required information to ensure that safe recruitment practices are being followed. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 6 The organisation must ensure that the agency staff have up to date mandatory training. The manager should develop a system of recording staff training, which would enable her to ensure that all staff have the required up to date mandatory training. The policy folder should be reorganised with the policies made more accessible. The organisation must ensure that any event which affects the well being of service users is reported to the Commission. The organisation must ensure that the decision to seek or not to seek medical advice for service users following an accident or incident is appropriately managed. Improvements are required to health and safety practices. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards were assessed at this inspection. The key standards were assessed at the previous announced inspection. Under standard 2 a requirement was made at the previous announced inspection that the statement of purpose or admissions procedure must outline the criteria for admission. The action plan from the organisation indicated that the criteria had been drawn up which is specific to the home. The admissions criteria was not viewed at this inspection. A requirement was made at the previous announced inspection that the organisation must ensure that the assessment documentation is fully completed for all future admissions to the home. The action plan from the organisation indicated that this would be done. The home has had no new admissions since the previous announced inspection therefore the compliance with this requirement was unable to be assessed. Under standard 5 a requirement was made at the previous announced inspection that the contract must be developed in line with standard 5.2 and contracts must be signed by service users representative or advocate. The action plan from the organisation indicated that the manager had arranged to do this with the advocate at the next service users meeting. The progress in meeting this requirement was not established at this inspection and will be followed up at the next announced inspection. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Service user plans do not include dates of the implementation of guidelines, guidelines do not show evidence of being reviewed and information on supporting service users to meet personal care needs have not been updated to reflect changes in service users needs which potentially puts service users at risk. Risk assessments are not kept updated and reviewed which could compromise the safety of service users and staff. EVIDENCE: Three service user plans were seen at this inspection. The service user plans seen include a photograph, a pen picture and lifestyle plan which outlines how the service user communicates, support required with personal care, support required with moving and handling, support required at meal times, likes and dislikes and behaviours. There was no indication that the pen pictures and lifestyle plans had been updated since the service users moved into the home. Service user files included a link worker planner, which outlined appointments and special dates for individuals. One of the planner’s seen had no entries from June to December. Service user plans included a daily dairy and nighttime Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 10 diary, a record of activities that had taken place, a record of family and friends visits, weight monitoring charts and a record of all health care appointments. One service user plan seen was disorganised with some information filed upside down. One service user plan seen included support plans, which did not appear to have been worked on with the service user since 2004. One service user plan seen included an in house review summary. This review summary indicated that the service user had lost weight and that the individuals mobility had gone down however there was no indication of action taken to address this change and the service users plan or risk assessments were not updated to address this significant change in the service user. Service user plans included guidelines on managing challenging behaviours, guidelines for supporting individuals in and out of the home and guidelines for supporting individuals at meal times. A requirement was made at the previous announced inspection that guidelines on supporting service users to mange behaviours and meet identified needs must include a date of implementation, written evidence of being reviewed and confirmation of being discussed with service users or not discussed with service users. This has not been complied with and some of the guidelines in place have not been updated since 2003. The manager confirmed that she has planned dates with her service manager to update and revamp service user files. This requirement will be repeated at this inspection. Service user plans included a series of generic risk assessments on burning from the cooker, choking, use of toiletries, being offered hot drinks or food by others and an individual risk assessments on behaviour that challenges. The risk assessments in two of the service user plans seen were overdue for review. The risk assessments and review documentation in some files was not filed together and was found to be disorganised and difficult to track if a review had taken place. A requirement was made at the previous announced inspection that all risk assessments must identify the level of risk and indicate if discussed with service users. Some individual risk assessments did not indicate the level of risk and did not indicate if the management plan reduced the risk. Risk assessments showed no evidence of service user/ representative or advocate involvement. This requirement will be repeated at this inspection. Service user plans include moving and handling risk assessments. Some of the moving and handling risk assessments seen were overdue for review. A requirement was made at the previous announced inspection that the missing persons procedure must be updated to indicate that if a service user goes missing the Commission must be informed. The action plan from the organisation indicated that this procedure would be updated by the 30th June 2005.The missing person policy at the home indicates this has not been complied with. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standard were assessed at this inspection. All of the key standards were assessed at the previous announced inspection. Under standard 12 a requirement was made at the previous announced inspection that the level of support required by service users to manage their post must be outlined within the service user plan. The manager has developed guidelines for staff on how individual service users post should be managed which is kept in individuals bedrooms. All post received is signed for and indicates if any action was necessary. Under standard 16 a recommendation was made at the previous inspection that service user plans should identify any other names the service user is happy to be called by and staff should only use abbreviations for service users if this has been agreed and recorded. The manager has developed this for one service user and intends to put this in place in all of the service user plans as part of the review and update of service user plans. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 12 Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards were assessed at this inspection. All of the key standards were assessed at the previous announced inspection. Under standard 19 service user plans include weight-monitoring charts. However service user plans did not indicate the frequency of checking individuals weight and some service users did not have their weight checked for a period of four months. An in house six monthly review report indicate that one service user had lost weight but there was no indication of any action being taken to address the weight loss. The manager must ensure that service user plans outline the frequency for monitoring weight and the action to be taken if significant increase or decrease in weight. One of the service user plans seen indicates that staff are to support the service user with an “exercise programme” however there is no reference or guidelines as to what this exercise programme is. Another service user’s plan indicates that staff are to carry out “bilateral massage” as instructed by the physiotherapist. The service user plan does not indicate what is “bilateral massage” and there are no written guidelines in place from the physiotherapist to support this or to indicate that the physiotherapist has assessed individual Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 14 staff and considers them competent to carry out this treatment. This must be addressed to ensure the safety of service users. Under standard 20 a requirement was made at the previous announced inspection that the organisation must ensure that medication assessments are completed and signed off prior to staff taking responsibility for administering medication. The manager confirmed she has assessed all staff who are responsible for administering medication. Evidence of those assessments were not requested at this inspection. The manager confirmed that individual medication cabinets have been obtained for service users bedrooms and the home is in the process of moving the medication from the office into service user bedrooms. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Complaints are acted on and dealt with appropriately to safeguard service users. EVIDENCE: The home has a complaints procedure in place, which indicates that complaints will be responded to within 28 days. At the previous announced inspection a log of complaints was not available at the home and a requirement was made to address this. At this inspection a log of complaints is now in place, which includes the complaint and a copy of a response to the complaint. The complaints log indicates that there has been one complaint since the last inspection, which was handled appropriately. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The home is bright and welcoming and plans are in place to further develop the home to benefit service users. The home is generally clean, but some areas require a deep clean and service users laundry must be appropriately managed to benefit service users. EVIDENCE: The home is homely, bright and welcoming. The kitchen, dining area and sitting room are showing signs of wear and tear. The manager confirmed that the kitchen area is to be revamped to prevent service users from being able to access the kitchen area unsupervised when the meal is being cooked to ensure the safety of individuals. The dresser in the dining area is badly scuffed and stained. All of the internal doors are wheelchair accessible however they are starting to become badly damaged and scuffed by wheelchairs. The home has one bathroom with a bath, shower and toilet and a further single toilet. The manager confirmed that this does not offer sufficient facilities for service users particularly in the morning and at bedtime. The organisation is currently considering providing an en suite shower in one of the bedrooms to address this. There has been a pipe leak on the internal wall of the shower room, which has been addressed and is due to be redecorated once the area has dried out. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 17 A requirement was made at the previous announced inspection that the organisation must ensure that the grass is mowed and made accessible and safe for service users. The manager confirmed that a gardener now comes in on a regular basis to keep the garden maintained. The manager confirmed that she has plans in place to develop part of the garden into a multi sensory area and is having the rear patio extended to ensure the safety of service users in wheelchairs when accessing the garden. The area to the front of the home has been made more secure with a fence and gate in place and there is a plan to have more car parking spaces made available. The manager confirmed that she has obtained quotes to have the garage converted into a multi sensory area for service users. The home was generally clean and tidy although there was a build up of dirt under the fridge freezers. There was an odour in the bathroom, which may be as a result of the dampness in this area. Staff are responsible for the cleaning of the home and cleaning schedules are in place for staff to follow to maintain an accepted level of cleanliness. The home has a separate laundry room and the washing machine has sluicing facilities. The laundry room was untidy with clean and dirty laundry piled up in a heap on top of the washing machine. There was a broken clothes stand in the laundry room with clothes still on it. This should be replaced and the manager should consider how service users laundry is managed. The home has health and safety polices in place, including procedures on the management of clinical waste, dealing with spillages and use of protective clothing. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 34 Safe staffing levels are being maintained to ensure the safety of service users and staff. Recruitment practices are unsafe and potentially put service users at risk. EVIDENCE: The home has been successful in recruiting into some of the care staff vacancies. At the time of this inspection the home had a 37.5 hour care staff vacancy, which has been filled and was waiting for confirmation of a start date for that individual. The home has a further thirty - hour care staff vacancy, which the organisation is attempting to recruit into. The rota indicate that there is a minimum of three staff on each day time shift with a fourth member of staff on shift as required to support one service user to have two to one support for any activities in the community. The home continues to use agency staff to cover the vacancies but try to use the same agency staff to provide continuity for service users. The rota indicates that there is a permanent member of staff on duty on each shift with agency staff and new or inexperienced staff. The home has one waking night staff and a sleep in member of staff. Requirements made at the previous announced inspection to ensure safe staffing levels are maintained has been complied with and will continue to be monitored. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 19 The organisation has appointed a manager and deputy manager. The manager and deputy manager have allocated administration time and cover shifts each week. Staff are responsible for the cooking and cleaning. Staff meeting minutes indicate that staff meetings took place in February, March and August. The file contained the agenda for two meetings in September but no minutes from those meetings were available. The manager confirmed that she aims to have the staff meeting every four to six weeks. This is crucial in the development of a new staff team. Three staff files were requested at this inspection. The files requested were for new staff appointed to the home since the previous announced inspection. One of the staff files seen included a copy of the application form, a photograph, copies of two references but no confirmation of CRB clearance. The other two staff files seen had none of the required schedule 2 and 4(6) information. A requirement was made at two previous inspections that the organisation must ensure that all staff files contain all of the information as outlined in Schedule 2 & 4(6). The action plan received from the organisation in response to the previous announced inspection report indicated that the requirement would be met by the due date, which has not been complied with. The manager rang the human resources department during the inspection to request this information to enable those individual staff to continue to work at the home. The human resources department advised her she would have to go up to their head office in Hemel Hempstead to obtain this information. A further request was made to the human resources to request in writing confirmation that the individual staff concerned had two references on file and CRB clearance to enable the manager to adequately staff the home without compromising service users safety until such time as she could get to the head office to obtain this information. This information was faxed to the home prior to the end of the inspection. The manager must check all staff files and ensure that the staff files contain all of the information as outlined in schedule 2 & 4(6). Any new staff to the home must not work at the home until such time as she has obtained this information. The organisation is reminded that continued breach of this regulation may lead to enforcement action. The manager advised she does not get to see references prior to a member of staff being given the all clear to start. At a meeting with the Commission the organisation agreed to address this, which does not appear to be the case. The home uses agency staff and has obtained confirmation from the agencies that individual staff have two references and CRB clearance with the CRB number. Standard 35 was not assessed at this inspection. A requirement was made at the previous announced inspection that the organisation must obtain written confirmation from the agencies of what training agency staff have had and date of training. The agencies have confirmed what training staff have had but in some cases there is no date to indicate when the training took place and for some agency staff it indicates that mandatory training is overdue. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 20 Requirements were made at the previous announced inspection that the organisation must ensure that new staff are not working unsupervised and as shift leader without the mandatory training and challenging behaviour training. The manager confirmed that she identifies staff who require mandatory training, challenging behaviour training and other training during their supervision. She then requests this training from head office. Training is recorded in individual staff files. Staff are responsible for keeping those files up to date. At this inspection it was difficult to establish if all staff have up to date mandatory training and challenging behaviour training without going through the rota, each individual file and training records. The manager should consider gathering this information in a spreadsheet, which would enable her to keep a record of what training staff have had and act as a prompt when updates are due. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The organisation has appointed a registered manager to the home which will provide direction to the staff team and will enable them to provide a high standard of care to service users. Some health and safety practices are unsatisfactory and potentially put service users at risk. EVIDENCE: The organisation has been successful in recruiting a manager. The manager has been in post since May 2005 and is in the process of applying to the Commission to be registered. Her priority has been to recruit staff and develop the staff team and she continues to address this. The manager has been proactive in meeting some of the requirements from the previous announced inspection but recognises that some requirements have not been met in particular in relation to the development of service user files. She is committed to addressing this and has allocated dates to commence an overhaul of service users files. The manager is Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 22 proactive in ensuring that polices and procedures are understood and adhered to by staff and in developing procedures to improve practice. The relevant licences and certificates are displayed in the office. Standard 40 was not assessed however the policy folder is disorganised and it was difficult to access the relevant policies. The manager is proactive in ensuring that all staff have up to date mandatory training however it was not easily established if all staff have up to date mandatory training as outlined under standard 35. The home had an in house health and safety audit carried out in September 2005. An action plan is in place from the audit, which indicated that some action was still outstanding. The staff carry out water temperature checks of communal areas and bedrooms and records are maintained to support this. The home has it own transport and monthly vehicle checks are carried out. The records indicate that the insurance for the vehicle had expired in September 2005. The manager must check with the organisation if the vehicle’s insurance has been renewed. The home has a list of named drivers. This list does not indicate that staff’s driving licences are viewed and checked or the frequency of this check. The manager confirmed that this list is currently being updated and that driving licences are checked, copies taken and put on the staff’s personnel file at head office. The home has an up to date gas safety check certificate, which indicates that the annual service was carried out in December 2004. The portable appliance records on file indicate that there was no portable appliance testing since 2003. A memo on file and a sticker seen on some of the electrical equipment indicates it was carried out in November 2004 but no records were obtained. This service is now due and the manager agreed to chase it up with the maintenance department. The home has COSHH data sheets in place and generic risk assessments. The generic risk assessments are overdue for review. The manager was aware of this and confirmed that this is being addressed. The home has two first aid boxes and one, which is kept in the vehicle. The manager confirmed that staff check the contents of the first aid boxes but no records are in place to confirm this. The home has accidents and incident records. The records indicate a high number of accidents and incidents as a result of individuals challenging behaviour. The home does not notify the Commission as required under regulation 37 of accidents and incidents, which affect the well being of service users. This must be addressed. The service users accident records indicate that care staff are making decisions that service users do not require medical intervention. The manager must ensure that the decision to or not to seek medical advise is assessed after each accident and or incident and following discussion with a senior member of staff or as agreed as part of the management of challenging behaviours. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 23 The home carries out daily checks of fridge and freezers temperature. The fridge temperature records indicate that the fridge temperature is too warm but staff did not appear to recognise this or act on it. During the inspection it was established that the thermometer was reading incorrectly. The home keeps a record of cooked food temperatures. Those records were well maintained. The home carries out weekly fire call point tests. The records indicate that there was a gap in the records for the emergency lighting checks. The home carries out quarterly fire drills. The records indicate the last fire drill was in July 2005 and this was now overdue. Records indicate that the fire alarm and fire equipment has an up to date service. The home keeps a record of work reported to maintenance and date of when the work was completed. The maintenance records indicate a response of over a month to health and safety issues in relation to fire doors not closing and the front door not shutting. This is unacceptable and potentially puts service users at risk. Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 1 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wendover Road (87) Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000023084.V264999.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Guidelines on supporting service users to manage behaviours and meet identified needs must include a date of implementation, written evidence of being reviewed and confirmation of being discussed with service users or not discussed with service users. (Previous timescale of 31st May 2005 not met) Service user files including the pen picture and lifestyle plan must be kept updated to reflect changes in service users needs and to ensure continuity of care. All risk assessments must identify the level of risk and indicate if discussed with service users. (Previous timescale of the 31st May 2005 not met) Service users risk assessments, including moving and handling risk assessments must be kept up to date and reviewed. The missing person procedure must be updated to indicate that if a service user goes missing, the Commission must be informed. (Previous timescale DS0000023084.V264999.R01.S.doc Timescale for action 31/03/06 2. YA6 15 31/03/06 3. YA9 13 31/01/06 4 YA9 13 31/01/06 5. YA9 13 31/01/06 Wendover Road (87) Version 5.0 Page 26 of 30th June 2005 not met) 6 YA19 12 The manager must ensure that service user plans outline the frequency for monitoring weight and the action to be taken if significant increase or decrease in weight. The manager must ensure that service user plans specifically outline exercise programmes or massage treatments for service users and ensure that staff are trained and competent to deliver this treatment. The organisation must ensure that all staff files contain all of the information as outlined in schedule 2 and 4(6). (Previous timescale of the 31st October 2004 & 30th June 2005 not met) The organisation must ensure that confirmation is on file that agency staff have up to date mandatory training. The organisation must ensure that any event, which affects the well being of service users, is reported to the Commission. The manager must ensure that the home’s vehicle is insured and an up to date insurance certificate must be maintained at the home to confirm this. The manager must ensure that the decision to or not to seek medical advice is assessed after each service user accident and or incident and following discussion with a senior member of staff or as agreed as part of the management of challenging behaviours. The manager must ensure that staff follow food hygiene training in relation to fridge temperatures and ensure that they act if the DS0000023084.V264999.R01.S.doc 31/01/06 7. YA19 12 31/01/06 8. YA34 19 05/12/05 9. YA35 18 05/12/05 10 YA42 37 31/12/05 11. YA42 13 30/11/05 12. YA42 12 10/12/05 13 YA42 13 05/12/05 Wendover Road (87) Version 5.0 Page 27 14 YA42 23 15 YA42 23 temperatures is out of the safe range. The manager must ensure that the required fire check records are kept maintained and a fire drill to be organised and carried out quarterly as required by the organisation. The organisation must ensure that there is a speedy response to maintenance issues, which affects the well being of service users. 05/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard YA6 YA30 YA40 YA35 Good Practice Recommendations Service user plans should be organised and the information made more accessible. The broken clothes stand should be replaced and guidelines put in place as to how service users laundry should be managed. The policy folder should be reorganised and made more accessible. The manager should consider recording the teams training on a spreadsheet which would enable her to keep a record of what training staff have had and act as a prompt when updates are due. The manager should ensure that a record is put in place to confirm that first aid boxes have been checked and kept stocked. 5 YA42 Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wendover Road (87) DS0000023084.V264999.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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